G Model
PEDOT-7237; No. of Pages 4 International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.) Domenico Ciavarella *, Lucio Lo Russo, Mario Mastrovincenzo, Saverio Padalino, Graziano Montaruli, Giovanni Giannatempo, Michele Cassano, Luigi Laino, Lorenzo Lo Muzio Department of Clinical and Experimental Medicine, School of Dentistry, University of Foggia, via Rovelli 48, Foggia 71100, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 July 2014 Received in revised form 7 August 2014 Accepted 9 August 2014 Available online xxx
Introduction: Facial growth changes the position of the jaws (in particular vertical position of the maxilla and antero-posterior position of the mandible) and may, in turn, modify the position of the tongue and the hyoid bone, thus, generating modifications of the upper airway space. In the present paper, effects on upper airway space and tongue position of a new functional appliance, the swallowing occlusal contact intercept appliance (SOCIA) have been investigated. Materials and methods: Retrospective cephaolmetric study of twenty-four children (mean age 9.46 1.60) with hyperdivergent Class II malocclusion with mandibular retrusion and atypical deglutition, was performed on radiographs taken before and after 24 months treatment with ‘‘SOCIA’’ appliance. The variables considered in this study, and analysed by means of a Paired t-test with a 5% level of significance, included the distance between the base of epiglottis (EB) and the tip of the tongue (TT), the distance from the tongue dorsum to EB-TT (TGH), the distance between the posterior nasal spine PNS and EB (VAL), SPAS, MAS and IAS (i.e. superior, medium and inferior pharyngeal airspace width). Results: Our findings showed a significant increase in tongue length (TT-EB) and tongue height (TGH); thus, confirming the reposition of the tongue from a lower posture to its physiological position onto the palatal spot. These modifications of the tongue posture had effects on the upper airway space. The most important modifications were observed in SPAS, with a significant 5.9 mm increase. Some increase was found also for MAS (0.83 mm) and IAS (1.1 mm) but without statistical significance. A significant increase (7.75 mm) was also found for VAL, probably as a result of the augmentation of posterior facial height. Conclusions: SOCIA appliance is capable to improve tongue position and the superior posterior airway space, and, consequently, to improve deglutition, phonation and respiratory function. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Functional appliance Upper airway space Upper airway obstruction Cephalometric evaluation Open bite
1. Introduction Pharyngeal airway spaces are described as the distance between the posterior and anterior wall of the pharynx, where the bottom is localized at the base of the tongue [1,2]; its width is dependent on the soft palate, the tongue and the hyoid bone position [3]. Therefore, in patients with atypical deglutition, an abnormal tongue position could result in a reduction of these spaces [4–6]; in
* Corresponding author. Tel.: +39 0881588086. E-mail address: [email protected] (D. Ciavarella).
addition, there may be a reciprocal relation between upper airway and jaws position. In fact, the effects of airway obstruction on craniofacial growth have been recently studied: although no definitive evidence is available, some reports consider to be plausible that tonsillar hypertrophy or pharyngeal obstruction could lead to changes in oro-facial muscles (including the lingual muscles) and also in the position of the jaws [7,8]. On the other hand, modifications of the upper airway in children have been studied after orthodontic treatments inducing modifications in the antero-posterior position of the jaws (i.e. mandibular forward positioner [9,10] for the resolution of the Class II malocclusion), as well as transversal expansion of the maxilla (i.e. rapid maxillary expansion (RME) [2,11]). Nonetheless, the effects of such
http://dx.doi.org/10.1016/j.ijporl.2014.08.008 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
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PEDOT-7237; No. of Pages 4 D. Ciavarella et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
2
orthodontic treatments on upper airway remain controversial [12]. In addition, the role of the vertical growth of the inferior third of the face, which is strictly related to vertical growth of the jaws, has been proposed as an important determinant of upper airway obstruction [13], but has been very seldom studied. This was addressed in the present retrospective study, in which the modifications of the upper airway space in patients with open bite (OB) and hyperdivergent facial growth were evaluated after treatment with the swallowing occlusal contact intercept appliance (SOCIA): a functional orthodontic appliance used for lower facial vertical growth control and the correct tongue position restoring. 2. Patients and methods 2.1. Subjects Retrospective evaluation of data retrieved from clinical notes of twenty-four patients (16 boys and 8 girls, mean age 9.46 1.60 years) was performed; all of them had formerly received treatment for their malocclusion at the School of Dentistry of Foggia University (Italy). Written informed consent was provided by patients’ parents for inclusion of patients’ data in this study. For patients enrolment, the following inclusion criteria were used: anterior OB, hyperdivergent facial skeletal pattern (angle between palatal plane and mandibular plane 308; ANB angle 3.58; overjet 4 mm), late mixed or permanent dentition, and adequate growth potential evaluated using the cervical–vertebral maturation method (i.e. CS2, CS3 or CS4 stages); thus, patients with CS5 stage were excluded from the study. Other exclusion criteria were: unilateral cross bite, bilateral cross bite, hypodivergent facial growth, oral or systemic diseases, missing teeth, congenital malformations, previous orthodontic treatment. 2.2. Cephalometric evaluation Pre-treatment and post-treatment records available in clinical notes and used for diagnosis and management of patients’ malocclusion, included casts of maxillary and mandibular dental arches, photographs, panoramic radiographs and lateral-head films. Head films, essential for the care of the patients, were taken with the patient fixed in a cephalostat in centric occlusion, with adequate visualization of reference structures, and no appreciable rotation of the head. Cephalometric evaluation was retrospectively performed on radiographs taken for the diagnosis of the malocclusion (before treatment: T0), and at the end of active treatment (T1). Cephalometric landmarks are shown in Fig. 1, and corresponding measurements detailed in Table 1 [3]. Cephalometric evaluation was independently performed by two examiners: in case of disagreement, discussion between examiners on the identification of specific landmarks allowed to obtain the representative measurement to be included in the statistical analysis.
Fig. 1. Cephalometric landmarks.
2.3. Swallowing occlusal contact intercept appliance (SOCIA) description SOCIA appliance was custom made and built, for each patient, by a dental technician. Acrylic components consisted of a palatal body with a hole near palatal wrinkle and continuing with a sixty degrees tilted (with respect to an occlusal plane) lingual flight; vestibular pads positioned at a 4 mm distance buccally to the deciduous molars with metallic posterior bite blocks embedded in them are also present (Fig. 2). The vestibular pads are attached to palatal acrylic body using a 1.0 mm stainless steel wire running adjacent to the dentition and crossing the occlusal plane; a 1.1 mm diameter vestibular wire is also connected to the pads. SOCIA has no dental retention and it is held in place solely by stimulation of the masticatory muscles. By actively biting on
Table 1 Cephalometric measurements. TT-EB
Linear distance between epiglottis base (EB) and tongue tip (TT)
TGH
Maximum tongue height measured on a line perpendicular to EB-TT to tongue dorsum Linear distance between posterior nasal spine (PNS) and EB Superior posterior airway space (width of airway behind soft palate along a line parallel to Gonion–Menthon (Go–Me) plane) Medium airway width measured on a line parallel to Go–Me plane passing through tip of soft palate (P) Inferior airway width measured on Go-Me plane Linear distance between PNS and P
VAL SPAS MAS IAS PNS-P
Fig. 2. (a) The SOCIA functional oral appliance; (b) patient wearing SOCIA.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
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posterior bite blocks, molar extrusion is prevented and vertical growth of the mandibular ramus is induced. Stimulation from the palatal button trains the tongue to reach its physiologic position near the upper incisors. Maxillary expansion is induced by the forces applied by the tongue in its new palatal position and by the vestibular pads, which relieve pressure generated from the oral musculature on teeth. The vestibular wire holds the sagittal position of the maxillary incisors. Patients were instructed to wear the SOCIA for 16 h per day, i.e. during the night and in the afternoon, and to remove it during eating and brushing. Active treatment lasted 24 months for all patients; all patients were revised on a regular monthly basis. 2.4. Statistical analysis Cephalometric data at T0 and T1 were compared and processed using the statistical software ‘‘GraphPad’’ by means of a Paired ttest with a 5% level of significance. 3. Results Results are detailed in Table 2. The appliance was easily accepted and no need for extensive education, in order to achieve satisfactory usage, was expressed by the parents. Patients undergoing myofunctional therapy with SOCIA showed a statistically significant increase of tongue length TT-EB (P = 0.0014), TGH (P = 0.0098), VAL (P = 0.0208) and SPAS (P = 0.0001). No statistically significant changes were observed for PNS-P (P = 0.2023), MAS (P = 0.3760) and IAS (P = 0.5249). 4. Discussion The upper airway space is restricted by the upper soft palate (superior posterior airway space), the medium soft palate (medium airway space), the base of the tongue and the epiglottis (inferior airway space) [14,15]. Early diagnosis and treatment of the factors producing an upper airway obstruction is extremely relevant. One of these factors is the facial growth pattern. In fact, facial growth changes the position of the jaws (in particular vertical position of the maxilla and antero-posterior position of the mandible) and may, in turn, modify the position of the tongue and the hyoid bone, thus, generating modifications of the upper airway space. In fact, it has been reported that hyperdivergent maxillary growth is associated with a narrower antero-posterior pharyngeal dimension compared to normodivergent growth [13]; in addition, mandibular prognathism is associated with considerably larger PAS [16], thus confirming that mandibular retrognathia is a common cause of the closure of the airway space as a result of the modifications of the position of the tongue because of the genioglossus muscle insertion on the mandible. Vertical and antero-posterior position of the jaws, may also affect results of Table 2 T0 vs. T1 cephalometric measurements statistics. T1
T0
TT-EB TGH VAL PNS-P SPAS MAS IAS *
P-value
Mean
SD
Mean
SD
71.666 30.083 51.000 31.416 12.166 12.250 9.200
6.301 2.968 16.170 7.692 3.380 3.279 5.412
79.000 33.166 58.750 34.416 18.083 13.083 10.300
5.510 3.129 11.371 9.346 3.801 3.919 5.945
Statistically significant. P-value < 0.05.
0.0014* 0.0098* 0.0208* 0.2023 0.0001* 0.3760 0.5249
3
surgical treatment for obstructive sleep apnea syndrome (OSAS); in fact, patients with skeletal Class II, a more retrognathic mandible, and a hyperdivergent vertical pattern with a larger mandibular plane angle have worse results from such a surgery [17]. Now, it could be possible that orthodontic appliances and/or treatments capable to modify facial growth pattern may have effects also on upper airway space. Under this point of view, the modifications of the upper airway space after orthodontic treatment are still unclear and contradictory data have been reported [18]. Few studies evaluated the effects on the upper airway space of functional or fixed appliances used to treat malocclusions in children [9]. Modification of transversal dimension of the upper jaw by means of RME [2,12,19] has been often investigated; RME has been shown to be associated with a reduction of nasal resistance and maximal negative pressure in pharingeal airway during inspiration [12], although, the mechanism underlying the effects of RME on OSAS in children is still unclear. Modification of the sagittal position of the jaws [20] may influence the airway space, too. Han et al. showed that patients with class II malocclusion had an increase of the pharyngeal airway after treatment with bionator [21]; the same has been advocated with the use of the activatorheadgear therapy [22]. Twin block appliance in class II malocclusion has been observed to significantly increase upper and lower pharyngeal width and area of bony nasopharynx [23,24]. In the present retrospective study, authors evaluated the effects on upper airway space and tongue position of a new functional appliance, the SOCIA, used in treatment of patients with hyperdivergent facial growth and Class II malocclusion with mandibular retrusion, two conditions often associated in the same patients and potentially associated with upper airway obstruction. The use of this oral appliance is indicated in children with an atypical swallowing and lower tongue posture. SOCIA effects are: (i) reduction of the divergent facial growth pattern and increase of the posterior facial height by means of posterior bites blocks; (ii) upper jaw transversal expansion by means of two vestibular acrylic pads and lingual muscles activation to hold the appliance in place. Its effects on upper airway space were evaluated at three levels: superior posterior airway space (SPAS), the medium posterior airway space (MAS) and the inferior posterior airway space (IAS). Our findings showed a significant increase in tongue length, i.e. distance from the tip of the tongue to the base of epiglottis (TT-EB), and increase of the tongue height (TGH); thus, confirming the reposition of the tongue from a lower posture to its physiological position onto the palatal spot. These modifications of the tongue posture had effects on the upper airway space. The most important modifications were observed in SPAS. This space had a significant 5.9 mm increase. Some increase was found also for MAS (0.83 mm) and IAS (1.1 mm) but without statistical significance. A significant increase (7.75 mm) was also found for the distance between posterior nasal spine and the epiglottis base (VAL); it is our opinion that such an increase was related to the augmentation of posterior facial height. In conclusion, SOCIA appliance is capable to improve tongue position and the superior posterior airway space, and, consequently, to improve deglutition, phonation and respiratory function [25]. Conflict of interest statement All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence (bias) this work.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
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References [1] A.C. de Souza Carvalho, O. Magro Filho, I.R. Garcia Jr., P.M. Araujo, R.L. Nogueira, Int. J. Oral. Maxillofac. Surg. 41 (2012) 1102–1111. [2] F. Aloufi, C.B. Preston, K.H. Zawawi, ISRN Dentistry 2012 (2012) 290964. [3] Y. Liu, A.A. Lowe, J.A. Fleetham, Y.C. Park, Am. J. Orthod. Dentofacial Orthop. 120 (2001) 639–647 (official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics). [4] A.J. Machado Jr., A.N. Crespo, Braz. J. Otorhinolaryngol. 78 (2012) 120–125. [5] S. Saccomanno, G. Antonini, L. D’Alatri, M. D’Angelantonio, A. Fiorita, R. Deli, Eur. J. Paediatr. Dent. 13 (2012) 321–323. [6] R. Condo, M. Costacurta, C. Perugia, R. Docimo, Eur. J. Paediatr. Dent. 13 (2012) 209–214. [7] F.C. Valera, L.V. Travitzki, S.E. Mattar, M.A. Matsumoto, A.M. Elias, W.T. AnselmoLima, Int. J. Pediatr. Otorhinolaryngol. 67 (2003) 761–770. [8] I.P. Adamidis, M.N. Spyropoulos, Eur. J. Orthod. 5 (1983) 287–294. [9] F. Ozdemir, F. Ulkur, D. Nalbantgil, Angle Orthod. 84 (2014) 260–264. [10] G. Kinzinger, K. Czapka, B. Ludwig, B. Glasl, U. Gross, J. Lisson, J. Orofac. Orthop. (Fortschr. Kieferorthop.), 72 (2011) 301–320 (Organ/official journal Deutsche Gesellschaft fur Kieferorthopadie). [11] A. Caprioglio, M. Meneghel, R. Fastuca, P.A. Zecca, R. Nucera, L. Nosetti, Int. J. Pediatr. Otorhinolaryngol. 78 (2014) 23–27. [12] T. Iwasaki, Y. Takemoto, E. Inada, H. Sato, H. Suga, I. Saitoh, E. Kakuno, R. Kanomi, Y. Yamasaki, Int. J. Pediatr. Otorhinolaryngol. 78 (8) (2014) 1258–1264.
[13] A.A. Joseph, J. Elbaum, G.J. Cisneros, S.B. Eisig, Int. J. Oral Maxillofac. Surg. 56 (1998) 135–139, Discussion 139–140, (official journal of the American Association of Oral and Maxillofacial Surgeons). [14] D. Ciavarella, L. Guida, G. Battista, M. Dioguardi, R. Sabato, M.P. Foschino Barbaro, D. Lacedonia, C. Chimenti, L. Perillo, M. Mastrovincenzo, L. Lo Muzio, Open Otorhinolaryngol. J. 6 (2012) 11–16. [15] C.D.V.A. Vicini, M. Benazzo, S. Frassineti, A. Campanini, F. Piercarlo, E. Mira, Eur. Arch. Oto-Rhino-Laryngol. 269 (2012) 1297–1300. [16] T.Y.A. Muto, S. Takeda, Int. J. Oral Maxillofac. Surg. 37 (2008) 228–231. [17] S.J.K.Y. Kim, J.H. Park, S.W. Kim, Int. J. Oral Maxillofac. Surg. 70 (2012) 1404–1412 (official journal of the American Association of Oral and Maxillofacial Surgeons). [18] N. Gkantidis, D.J. Halazonetis, E. Alexandropoulos, N.B. Haralabakis, Am. J. Orthod. Dentofacial Orthop. 140 (2011) 346–355 (official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics). [19] H.G. Hershey, B.L. Stewart, D.W. Warren, Am. J. Orthod. 69 (1976) 274–284. [20] M.M. Ozbek, T.U. Memikoglu, H. Gogen, A.A. Lowe, E. Baspinar, Angle Orthod. 68 (1998) 327–336. [21] S. Han, Y.J. Choi, J.Y. Chung C. j. Kim, K.H. Kim, Korean J. Orthod. 44 (2014) 13–19. [22] M.P. Hanggi, U.M. Teuscher, M. Roos, T.A. Peltomaki, Eur. J. Orthod. 30 (2008) 598–605. [23] S.K. Vinoth, A.V. Thomas, R. Nethravathy, J. Pharm. Bioallied Sci. 5 (2013) S25–S29. [24] A.K. Jena, S.P. Singh, A.K. Utreja, Angle Orthod. 83 (2013) 728–734. [25] S. Malkoc, S. Usumez, M. Nur, C.E. Donaghy, Am. J. Orthod. Dentofacial Orthop. 128 (2005) 513–516.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
PEDOT-7237; No. of Pages 4 International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.) Domenico Ciavarella *, Lucio Lo Russo, Mario Mastrovincenzo, Saverio Padalino, Graziano Montaruli, Giovanni Giannatempo, Michele Cassano, Luigi Laino, Lorenzo Lo Muzio Department of Clinical and Experimental Medicine, School of Dentistry, University of Foggia, via Rovelli 48, Foggia 71100, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 July 2014 Received in revised form 7 August 2014 Accepted 9 August 2014 Available online xxx
Introduction: Facial growth changes the position of the jaws (in particular vertical position of the maxilla and antero-posterior position of the mandible) and may, in turn, modify the position of the tongue and the hyoid bone, thus, generating modifications of the upper airway space. In the present paper, effects on upper airway space and tongue position of a new functional appliance, the swallowing occlusal contact intercept appliance (SOCIA) have been investigated. Materials and methods: Retrospective cephaolmetric study of twenty-four children (mean age 9.46 1.60) with hyperdivergent Class II malocclusion with mandibular retrusion and atypical deglutition, was performed on radiographs taken before and after 24 months treatment with ‘‘SOCIA’’ appliance. The variables considered in this study, and analysed by means of a Paired t-test with a 5% level of significance, included the distance between the base of epiglottis (EB) and the tip of the tongue (TT), the distance from the tongue dorsum to EB-TT (TGH), the distance between the posterior nasal spine PNS and EB (VAL), SPAS, MAS and IAS (i.e. superior, medium and inferior pharyngeal airspace width). Results: Our findings showed a significant increase in tongue length (TT-EB) and tongue height (TGH); thus, confirming the reposition of the tongue from a lower posture to its physiological position onto the palatal spot. These modifications of the tongue posture had effects on the upper airway space. The most important modifications were observed in SPAS, with a significant 5.9 mm increase. Some increase was found also for MAS (0.83 mm) and IAS (1.1 mm) but without statistical significance. A significant increase (7.75 mm) was also found for VAL, probably as a result of the augmentation of posterior facial height. Conclusions: SOCIA appliance is capable to improve tongue position and the superior posterior airway space, and, consequently, to improve deglutition, phonation and respiratory function. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Functional appliance Upper airway space Upper airway obstruction Cephalometric evaluation Open bite
1. Introduction Pharyngeal airway spaces are described as the distance between the posterior and anterior wall of the pharynx, where the bottom is localized at the base of the tongue [1,2]; its width is dependent on the soft palate, the tongue and the hyoid bone position [3]. Therefore, in patients with atypical deglutition, an abnormal tongue position could result in a reduction of these spaces [4–6]; in
* Corresponding author. Tel.: +39 0881588086. E-mail address: [email protected] (D. Ciavarella).
addition, there may be a reciprocal relation between upper airway and jaws position. In fact, the effects of airway obstruction on craniofacial growth have been recently studied: although no definitive evidence is available, some reports consider to be plausible that tonsillar hypertrophy or pharyngeal obstruction could lead to changes in oro-facial muscles (including the lingual muscles) and also in the position of the jaws [7,8]. On the other hand, modifications of the upper airway in children have been studied after orthodontic treatments inducing modifications in the antero-posterior position of the jaws (i.e. mandibular forward positioner [9,10] for the resolution of the Class II malocclusion), as well as transversal expansion of the maxilla (i.e. rapid maxillary expansion (RME) [2,11]). Nonetheless, the effects of such
http://dx.doi.org/10.1016/j.ijporl.2014.08.008 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
G Model
PEDOT-7237; No. of Pages 4 D. Ciavarella et al. / International Journal of Pediatric Otorhinolaryngology xxx (2014) xxx–xxx
2
orthodontic treatments on upper airway remain controversial [12]. In addition, the role of the vertical growth of the inferior third of the face, which is strictly related to vertical growth of the jaws, has been proposed as an important determinant of upper airway obstruction [13], but has been very seldom studied. This was addressed in the present retrospective study, in which the modifications of the upper airway space in patients with open bite (OB) and hyperdivergent facial growth were evaluated after treatment with the swallowing occlusal contact intercept appliance (SOCIA): a functional orthodontic appliance used for lower facial vertical growth control and the correct tongue position restoring. 2. Patients and methods 2.1. Subjects Retrospective evaluation of data retrieved from clinical notes of twenty-four patients (16 boys and 8 girls, mean age 9.46 1.60 years) was performed; all of them had formerly received treatment for their malocclusion at the School of Dentistry of Foggia University (Italy). Written informed consent was provided by patients’ parents for inclusion of patients’ data in this study. For patients enrolment, the following inclusion criteria were used: anterior OB, hyperdivergent facial skeletal pattern (angle between palatal plane and mandibular plane 308; ANB angle 3.58; overjet 4 mm), late mixed or permanent dentition, and adequate growth potential evaluated using the cervical–vertebral maturation method (i.e. CS2, CS3 or CS4 stages); thus, patients with CS5 stage were excluded from the study. Other exclusion criteria were: unilateral cross bite, bilateral cross bite, hypodivergent facial growth, oral or systemic diseases, missing teeth, congenital malformations, previous orthodontic treatment. 2.2. Cephalometric evaluation Pre-treatment and post-treatment records available in clinical notes and used for diagnosis and management of patients’ malocclusion, included casts of maxillary and mandibular dental arches, photographs, panoramic radiographs and lateral-head films. Head films, essential for the care of the patients, were taken with the patient fixed in a cephalostat in centric occlusion, with adequate visualization of reference structures, and no appreciable rotation of the head. Cephalometric evaluation was retrospectively performed on radiographs taken for the diagnosis of the malocclusion (before treatment: T0), and at the end of active treatment (T1). Cephalometric landmarks are shown in Fig. 1, and corresponding measurements detailed in Table 1 [3]. Cephalometric evaluation was independently performed by two examiners: in case of disagreement, discussion between examiners on the identification of specific landmarks allowed to obtain the representative measurement to be included in the statistical analysis.
Fig. 1. Cephalometric landmarks.
2.3. Swallowing occlusal contact intercept appliance (SOCIA) description SOCIA appliance was custom made and built, for each patient, by a dental technician. Acrylic components consisted of a palatal body with a hole near palatal wrinkle and continuing with a sixty degrees tilted (with respect to an occlusal plane) lingual flight; vestibular pads positioned at a 4 mm distance buccally to the deciduous molars with metallic posterior bite blocks embedded in them are also present (Fig. 2). The vestibular pads are attached to palatal acrylic body using a 1.0 mm stainless steel wire running adjacent to the dentition and crossing the occlusal plane; a 1.1 mm diameter vestibular wire is also connected to the pads. SOCIA has no dental retention and it is held in place solely by stimulation of the masticatory muscles. By actively biting on
Table 1 Cephalometric measurements. TT-EB
Linear distance between epiglottis base (EB) and tongue tip (TT)
TGH
Maximum tongue height measured on a line perpendicular to EB-TT to tongue dorsum Linear distance between posterior nasal spine (PNS) and EB Superior posterior airway space (width of airway behind soft palate along a line parallel to Gonion–Menthon (Go–Me) plane) Medium airway width measured on a line parallel to Go–Me plane passing through tip of soft palate (P) Inferior airway width measured on Go-Me plane Linear distance between PNS and P
VAL SPAS MAS IAS PNS-P
Fig. 2. (a) The SOCIA functional oral appliance; (b) patient wearing SOCIA.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
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posterior bite blocks, molar extrusion is prevented and vertical growth of the mandibular ramus is induced. Stimulation from the palatal button trains the tongue to reach its physiologic position near the upper incisors. Maxillary expansion is induced by the forces applied by the tongue in its new palatal position and by the vestibular pads, which relieve pressure generated from the oral musculature on teeth. The vestibular wire holds the sagittal position of the maxillary incisors. Patients were instructed to wear the SOCIA for 16 h per day, i.e. during the night and in the afternoon, and to remove it during eating and brushing. Active treatment lasted 24 months for all patients; all patients were revised on a regular monthly basis. 2.4. Statistical analysis Cephalometric data at T0 and T1 were compared and processed using the statistical software ‘‘GraphPad’’ by means of a Paired ttest with a 5% level of significance. 3. Results Results are detailed in Table 2. The appliance was easily accepted and no need for extensive education, in order to achieve satisfactory usage, was expressed by the parents. Patients undergoing myofunctional therapy with SOCIA showed a statistically significant increase of tongue length TT-EB (P = 0.0014), TGH (P = 0.0098), VAL (P = 0.0208) and SPAS (P = 0.0001). No statistically significant changes were observed for PNS-P (P = 0.2023), MAS (P = 0.3760) and IAS (P = 0.5249). 4. Discussion The upper airway space is restricted by the upper soft palate (superior posterior airway space), the medium soft palate (medium airway space), the base of the tongue and the epiglottis (inferior airway space) [14,15]. Early diagnosis and treatment of the factors producing an upper airway obstruction is extremely relevant. One of these factors is the facial growth pattern. In fact, facial growth changes the position of the jaws (in particular vertical position of the maxilla and antero-posterior position of the mandible) and may, in turn, modify the position of the tongue and the hyoid bone, thus, generating modifications of the upper airway space. In fact, it has been reported that hyperdivergent maxillary growth is associated with a narrower antero-posterior pharyngeal dimension compared to normodivergent growth [13]; in addition, mandibular prognathism is associated with considerably larger PAS [16], thus confirming that mandibular retrognathia is a common cause of the closure of the airway space as a result of the modifications of the position of the tongue because of the genioglossus muscle insertion on the mandible. Vertical and antero-posterior position of the jaws, may also affect results of Table 2 T0 vs. T1 cephalometric measurements statistics. T1
T0
TT-EB TGH VAL PNS-P SPAS MAS IAS *
P-value
Mean
SD
Mean
SD
71.666 30.083 51.000 31.416 12.166 12.250 9.200
6.301 2.968 16.170 7.692 3.380 3.279 5.412
79.000 33.166 58.750 34.416 18.083 13.083 10.300
5.510 3.129 11.371 9.346 3.801 3.919 5.945
Statistically significant. P-value < 0.05.
0.0014* 0.0098* 0.0208* 0.2023 0.0001* 0.3760 0.5249
3
surgical treatment for obstructive sleep apnea syndrome (OSAS); in fact, patients with skeletal Class II, a more retrognathic mandible, and a hyperdivergent vertical pattern with a larger mandibular plane angle have worse results from such a surgery [17]. Now, it could be possible that orthodontic appliances and/or treatments capable to modify facial growth pattern may have effects also on upper airway space. Under this point of view, the modifications of the upper airway space after orthodontic treatment are still unclear and contradictory data have been reported [18]. Few studies evaluated the effects on the upper airway space of functional or fixed appliances used to treat malocclusions in children [9]. Modification of transversal dimension of the upper jaw by means of RME [2,12,19] has been often investigated; RME has been shown to be associated with a reduction of nasal resistance and maximal negative pressure in pharingeal airway during inspiration [12], although, the mechanism underlying the effects of RME on OSAS in children is still unclear. Modification of the sagittal position of the jaws [20] may influence the airway space, too. Han et al. showed that patients with class II malocclusion had an increase of the pharyngeal airway after treatment with bionator [21]; the same has been advocated with the use of the activatorheadgear therapy [22]. Twin block appliance in class II malocclusion has been observed to significantly increase upper and lower pharyngeal width and area of bony nasopharynx [23,24]. In the present retrospective study, authors evaluated the effects on upper airway space and tongue position of a new functional appliance, the SOCIA, used in treatment of patients with hyperdivergent facial growth and Class II malocclusion with mandibular retrusion, two conditions often associated in the same patients and potentially associated with upper airway obstruction. The use of this oral appliance is indicated in children with an atypical swallowing and lower tongue posture. SOCIA effects are: (i) reduction of the divergent facial growth pattern and increase of the posterior facial height by means of posterior bites blocks; (ii) upper jaw transversal expansion by means of two vestibular acrylic pads and lingual muscles activation to hold the appliance in place. Its effects on upper airway space were evaluated at three levels: superior posterior airway space (SPAS), the medium posterior airway space (MAS) and the inferior posterior airway space (IAS). Our findings showed a significant increase in tongue length, i.e. distance from the tip of the tongue to the base of epiglottis (TT-EB), and increase of the tongue height (TGH); thus, confirming the reposition of the tongue from a lower posture to its physiological position onto the palatal spot. These modifications of the tongue posture had effects on the upper airway space. The most important modifications were observed in SPAS. This space had a significant 5.9 mm increase. Some increase was found also for MAS (0.83 mm) and IAS (1.1 mm) but without statistical significance. A significant increase (7.75 mm) was also found for the distance between posterior nasal spine and the epiglottis base (VAL); it is our opinion that such an increase was related to the augmentation of posterior facial height. In conclusion, SOCIA appliance is capable to improve tongue position and the superior posterior airway space, and, consequently, to improve deglutition, phonation and respiratory function [25]. Conflict of interest statement All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence (bias) this work.
Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
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Please cite this article in press as: D. Ciavarella, et al., Cephalometric evaluation of tongue position and airway remodelling in children treated with swallowing occlusal contact intercept appliance (S.O.C.I.A.), Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/ 10.1016/j.ijporl.2014.08.008
